Letters to the Editor Bordetella petrii Sinusitis in an Immunocompromised Adolescent To The Editors:
T
he Bordetella genus includes 9 member species, the best known of which is Bordetella pertussis. First identified in 2001, Bordetella petrii is the only Bordetella species which has been isolated from an environmental source and which therefore can exist outside of an obligatory host.1 It is also the only species capable of anaerobic growth and has been isolated from diverse ecologic niches such as marine sponges,2 polluted soil3 and river sediment.1 We highlight the potential for human infection with the description of a case of B. petrii sinusitis in an immunocompromised adolescent female. A 12-year-old girl with a history of hypogammaglobulinemia and specific antibody deficiency, complicated by chronic allergic fungal sinusitis, presented with worsening facial pain and thick, green, blood-tinged nasal discharge. Her history was notable for hypogammaglobulinemia and specific antibody deficiency first diagnosed at age 3. Although her specific immunodeficiency was unknown, it was thought to represent a qualitative B-cell impairment given her hypogammaglobulinemia despite normal B-cell numbers. She had a history of recurrent sinus infections which previously yielded isolates of Cladosporium, Penicillium and Aspergillus genera. Her medications at the time of admission included monthly intravenous immunoglobulin, oral prednisone, cetirizine, albuterol, amitriptyline, venlafaxine, budesonide, fluticasone–salmeterol and omalizumab. She had been empirically started on oral and intranasal itraconazole 4 days before presentation by her primary allergist because of concern for a fungal infection. On admission, physical examination was notable for normal vital signs, tenderness to palpation over the maxillary sinuses bilaterally and a nonfocal neurologic assessment. Laboratory studies showed a white blood cell count of 10,300 per μL and erythrocyte sedimentation rate of 25 mm/h. A computed tomography scan of the head was significant for right maxillary sinus mucosal thickening concerning for noninvasive J.M.N. and G.W.C. contributed equally to this work. The authors have no funding or conflicts of interest to disclose. Copyright © 2015 by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0891-3668/15/3404-0458 DOI: 10.1097/INF.0000000000000564
458 | www.pidj.com
fungal infection. Intravenous voriconazole was initiated given the history of fungal sinusitis. The patient then underwent bilateral endoscopic nasal debridement notable for thick, purulent maxillary drainage, more pronounced in the right sinus. The maxillary sinus cultures yielded growth of Aspergillus fumigatus and B. petrii, identified by matrix-assisted laser desorption ionization time-of-flight mass spectrometry.4 Susceptibility testing of B. petrii by epsilometry demonstrated minimum inhibitory concentrations of 1 µg/mL and 0.06 µg/mL for doxycycline and trimethoprim–sulfamethoxazole (TMP-SMX), respectively. After the identification of B. petrii, oral TMP-SMX was initiated, given published accounts of B. petrii susceptibility to and treatment with TMP-SMX.5,6 At 3-week follow-up, the patient reported resolution of her symptoms including facial pain and nasal discharge. The few examples of clinical infections involving B. petrii reported in the literature have been limited to immunocompetent adult populations.5,7,8 The first published description of B. petrii infection was in a 67-year-old patient with mandibular osteomyelitis.8 B. petrii has also been implicated as a pathogen in a 30-year-old patient with suppurative mastoiditis5 and a 79-year-old patient with bronchiectasis.7 We thus add to the growing literature describing pathogenic B. petrii to include disease in both pediatric and immunocompromised patients.
Jason M. Nagata, MD, MSc Gregory W. Charville, BS Jenna M. Klotz, MD Walter R. Wickremasinghe, MD Dylan C. Kann, MD Hayden T. Schwenk, MD, MPH Christopher A. Longhurst, MD, MS
Department of Pediatrics Stanford University School of Medicine Stanford, CA REFERENCES
1. von Wintzingerode F, Schattke A, Siddiqui RA, et al. Bordetella petrii sp. nov., isolated from an anaerobic bioreactor, and emended description of the genus Bordetella. Int J Syst Evol Microbiol. 2001;51(pt 4):1257–1265. 2. Sfanos K, Harmody D, Dang P, et al. A molecular systematic survey of cultured microbial associates of deep-water marine invertebrates. Syst Appl Microbiol. 2005;28:242–264. 3. Wang F, Grundmann S, Schmid M, et al. Isolation and characterization of 1,2,4-trichlorobenzene mineralizing Bordetella sp. and its bioremediation potential in soil. Chemosphere. 2007;67:896–902. 4. Patel R. Matrix-assisted laser desorption ionization-time of flight mass spectrometry in clinical microbiology. Clin Infect Dis. 2013;57:564–572.
5. Stark D, Riley LA, Harkness J, et al. Bordetella petrii from a clinical sample in Australia: isolation and molecular identification. J Med Microbiol. 2007;56(pt 3):435–437. 6. Zelazny AM, Ding L, Goldberg JB, et al. Adaptability and persistence of the emerging pathogen Bordetella petrii. PLoS One. 2013;8:e65102. 7. Le Coustumier A, Njamkepo E, Cattoir V, et al. Bordetella petrii infection with long-lasting persistence in human. Emerg Infect Dis. 2011;17:612–618. 8. Fry NK, Duncan J, Malnick H, et al. Bordetella petrii clinical isolate. Emerg Infect Dis. 2005;11:1131–1133.
Epstein–Barr Virus-associated Pericarditis and Pleural Effusions in a 4-yearold Girl To the Editors: ardiac manifestations of Epstein–Barr virus (EBV) infection are rare and include nonspecific electrocardiographic changes, myocarditis and pericarditis. We report a case of EBV pericarditis and pleural effusion in a previously healthy 4-year-old girl who presented with a 6-day history of fever reaching 40°C, nasal congestion, generalized fatigue, rapid breathing, abdominal pain, back pain and diarrhea. She had received ceftriaxone and amoxicillin without improvement. On initial examination, she was febrile (39.1°C), tachycardic and tachypneic with an oxygen saturation of 82% on room air responding to oxygen through nasal canula. She was irritable, had mild abdominal tenderness and mild cervical lymphadenopathy. Initial laboratory evaluation revealed normal blood chemistries and liver function tests, a white blood cell count of 13,700/mm3 (89.9% neutrophils), hemoglobin 10.6 g/dL and platelets 196,000/mm3. Initial chest radiograph was normal. Patient was treated empirically with vancomycin, ceftriaxone and azithromycin; however, fever persisted. Initial work-up for viral and bacterial etiologies of prolonged fever in this age group was negative including blood, urine and stool cultures; nasal wash viral culture; mycoplasma, IgM and IgG; cytomegalovirus, IgM and IgG; bartonella, IgM and IgG; antistreptolysin O titers, serum adenovirus and enterovirus polymerase chain reaction (PCR), TB quantiferon gold and human
C
The authors have no conflicts of interest to disclose. Copyright © 2015 by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0891-3668/15/3404-0458 DOI: 10.1097/INF.0000000000000581
The Pediatric Infectious Disease Journal • Volume 34, Number 4, April 2015
T
he Bordetella genus includes 9 member species, the best known of which is Bordetella pertussis. First identified in 2001, Bordetella petrii is the only Bordetella species which has been isolated from an environmental source and which therefore can exist outside of an obligatory host.1 It is also the only species capable of anaerobic growth and has been isolated from diverse ecologic niches such as marine sponges,2 polluted soil3 and river sediment.1 We highlight the potential for human infection with the description of a case of B. petrii sinusitis in an immunocompromised adolescent female. A 12-year-old girl with a history of hypogammaglobulinemia and specific antibody deficiency, complicated by chronic allergic fungal sinusitis, presented with worsening facial pain and thick, green, blood-tinged nasal discharge. Her history was notable for hypogammaglobulinemia and specific antibody deficiency first diagnosed at age 3. Although her specific immunodeficiency was unknown, it was thought to represent a qualitative B-cell impairment given her hypogammaglobulinemia despite normal B-cell numbers. She had a history of recurrent sinus infections which previously yielded isolates of Cladosporium, Penicillium and Aspergillus genera. Her medications at the time of admission included monthly intravenous immunoglobulin, oral prednisone, cetirizine, albuterol, amitriptyline, venlafaxine, budesonide, fluticasone–salmeterol and omalizumab. She had been empirically started on oral and intranasal itraconazole 4 days before presentation by her primary allergist because of concern for a fungal infection. On admission, physical examination was notable for normal vital signs, tenderness to palpation over the maxillary sinuses bilaterally and a nonfocal neurologic assessment. Laboratory studies showed a white blood cell count of 10,300 per μL and erythrocyte sedimentation rate of 25 mm/h. A computed tomography scan of the head was significant for right maxillary sinus mucosal thickening concerning for noninvasive J.M.N. and G.W.C. contributed equally to this work. The authors have no funding or conflicts of interest to disclose. Copyright © 2015 by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0891-3668/15/3404-0458 DOI: 10.1097/INF.0000000000000564
458 | www.pidj.com
fungal infection. Intravenous voriconazole was initiated given the history of fungal sinusitis. The patient then underwent bilateral endoscopic nasal debridement notable for thick, purulent maxillary drainage, more pronounced in the right sinus. The maxillary sinus cultures yielded growth of Aspergillus fumigatus and B. petrii, identified by matrix-assisted laser desorption ionization time-of-flight mass spectrometry.4 Susceptibility testing of B. petrii by epsilometry demonstrated minimum inhibitory concentrations of 1 µg/mL and 0.06 µg/mL for doxycycline and trimethoprim–sulfamethoxazole (TMP-SMX), respectively. After the identification of B. petrii, oral TMP-SMX was initiated, given published accounts of B. petrii susceptibility to and treatment with TMP-SMX.5,6 At 3-week follow-up, the patient reported resolution of her symptoms including facial pain and nasal discharge. The few examples of clinical infections involving B. petrii reported in the literature have been limited to immunocompetent adult populations.5,7,8 The first published description of B. petrii infection was in a 67-year-old patient with mandibular osteomyelitis.8 B. petrii has also been implicated as a pathogen in a 30-year-old patient with suppurative mastoiditis5 and a 79-year-old patient with bronchiectasis.7 We thus add to the growing literature describing pathogenic B. petrii to include disease in both pediatric and immunocompromised patients.
Jason M. Nagata, MD, MSc Gregory W. Charville, BS Jenna M. Klotz, MD Walter R. Wickremasinghe, MD Dylan C. Kann, MD Hayden T. Schwenk, MD, MPH Christopher A. Longhurst, MD, MS
Department of Pediatrics Stanford University School of Medicine Stanford, CA REFERENCES
1. von Wintzingerode F, Schattke A, Siddiqui RA, et al. Bordetella petrii sp. nov., isolated from an anaerobic bioreactor, and emended description of the genus Bordetella. Int J Syst Evol Microbiol. 2001;51(pt 4):1257–1265. 2. Sfanos K, Harmody D, Dang P, et al. A molecular systematic survey of cultured microbial associates of deep-water marine invertebrates. Syst Appl Microbiol. 2005;28:242–264. 3. Wang F, Grundmann S, Schmid M, et al. Isolation and characterization of 1,2,4-trichlorobenzene mineralizing Bordetella sp. and its bioremediation potential in soil. Chemosphere. 2007;67:896–902. 4. Patel R. Matrix-assisted laser desorption ionization-time of flight mass spectrometry in clinical microbiology. Clin Infect Dis. 2013;57:564–572.
5. Stark D, Riley LA, Harkness J, et al. Bordetella petrii from a clinical sample in Australia: isolation and molecular identification. J Med Microbiol. 2007;56(pt 3):435–437. 6. Zelazny AM, Ding L, Goldberg JB, et al. Adaptability and persistence of the emerging pathogen Bordetella petrii. PLoS One. 2013;8:e65102. 7. Le Coustumier A, Njamkepo E, Cattoir V, et al. Bordetella petrii infection with long-lasting persistence in human. Emerg Infect Dis. 2011;17:612–618. 8. Fry NK, Duncan J, Malnick H, et al. Bordetella petrii clinical isolate. Emerg Infect Dis. 2005;11:1131–1133.
Epstein–Barr Virus-associated Pericarditis and Pleural Effusions in a 4-yearold Girl To the Editors: ardiac manifestations of Epstein–Barr virus (EBV) infection are rare and include nonspecific electrocardiographic changes, myocarditis and pericarditis. We report a case of EBV pericarditis and pleural effusion in a previously healthy 4-year-old girl who presented with a 6-day history of fever reaching 40°C, nasal congestion, generalized fatigue, rapid breathing, abdominal pain, back pain and diarrhea. She had received ceftriaxone and amoxicillin without improvement. On initial examination, she was febrile (39.1°C), tachycardic and tachypneic with an oxygen saturation of 82% on room air responding to oxygen through nasal canula. She was irritable, had mild abdominal tenderness and mild cervical lymphadenopathy. Initial laboratory evaluation revealed normal blood chemistries and liver function tests, a white blood cell count of 13,700/mm3 (89.9% neutrophils), hemoglobin 10.6 g/dL and platelets 196,000/mm3. Initial chest radiograph was normal. Patient was treated empirically with vancomycin, ceftriaxone and azithromycin; however, fever persisted. Initial work-up for viral and bacterial etiologies of prolonged fever in this age group was negative including blood, urine and stool cultures; nasal wash viral culture; mycoplasma, IgM and IgG; cytomegalovirus, IgM and IgG; bartonella, IgM and IgG; antistreptolysin O titers, serum adenovirus and enterovirus polymerase chain reaction (PCR), TB quantiferon gold and human
C
The authors have no conflicts of interest to disclose. Copyright © 2015 by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0891-3668/15/3404-0458 DOI: 10.1097/INF.0000000000000581
The Pediatric Infectious Disease Journal • Volume 34, Number 4, April 2015
